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Schroeder L, Soltesz L, Leyens J, Strizek B, Berg C, Mueller A, Kipfmueller F. Vasoactive Management of Pulmonary Hypertension and Ventricular Dysfunction in Neonates Following Complicated Monochorionic Twin Pregnancies: A Single-Center Experience. CHILDREN (BASEL, SWITZERLAND) 2024; 11:548. [PMID: 38790543 PMCID: PMC11120423 DOI: 10.3390/children11050548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Twins resulting from a complicated monochorionic (MC) twin pregnancy are at risk for postnatal evolution of pulmonary hypertension (PH) and cardiac dysfunction (CD). Both pathologies are important contributors to short- and long-term morbidity in these infants. The aim of the present retrospective single-center cohort study was to evaluate the need for vasoactive treatment for PH and CD in these neonates. METHODOLOGY In-born neonates following a complicated MC twin pregnancy admitted to the department of neonatology of the University Children's Hospital Bonn (UKB) between October 2019 and December 2023 were screened for study inclusion. Finally, 70 neonates were included in the final analysis, with 37 neonates subclassified as recipient twins (group A) and 33 neonates as donor twins (group B). RESULTS The overall PH incidence at day of life (DOL) 1 was 17% and decreased to 6% at DOL 7 (p = 0.013), with no PH findings at DOL 28. The overall incidence of CD was 56% at DOL 1 and decreased strongly until DOL 7 (10%, p = 0.015), with no diagnosis of CD at DOL 28. The use of dobutamine, norepinephrine, and vasopressin at DOL 1 until DOL 7 did not differ between the subgroups, whereas the dosing of milrinone was significantly higher in Group B at DOL 1 (p = 0.043). Inhaled nitric oxide (iNO) was used in 16% of the cohort, and a levosimendan therapy was administered in 34% of the neonates. One-third of the cohort was treated with oral beta blockers, and in 10%, an intravenous beta blockade (landiolol) was administered. The maximum levosimendan vasoactive-inotropic score (LVISmax) increased from DOL 1 (12.4 [3/27]) to DOL 2 (14.6 [1/68], p = 0.777), with a significant decrease thereafter as measured at DOL 7 (9.5 [2/30], p = 0.011). CONCLUSION Early PH and CD are frequent diagnoses in neonates following a complicated MC twin pregnancy, and an individualized vasoactive treatment strategy is required in the management of these infants.
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Affiliation(s)
- Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Leon Soltesz
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Judith Leyens
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, 50931 Cologne, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
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McNamara PJ, Jain A, El-Khuffash A, Giesinger R, Weisz D, Freud L, Levy PT, Bhombal S, de Boode W, Leone T, Richards B, Singh Y, Acevedo JM, Simpson J, Noori S, Lai WW. Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:171-215. [PMID: 38309835 DOI: 10.1016/j.echo.2023.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.
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Affiliation(s)
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Regan Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Dany Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey Freud
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Tina Leone
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Yogen Singh
- Loma Linda University School of Medicine, Loma Linda, California
| | - Jennifer M Acevedo
- Department of Pediatrics-Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Simpson
- Department of Pediatrics, Evelina London Children's Hospital, London, United Kingdom
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Wyman W Lai
- CHOC Children's Hospital, Orange, California; University of California, Irvine, Orange, California
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Ruoss JL, Rios DR, Levy PT. Updates on Management for Acute and Chronic Phenotypes of Neonatal Pulmonary Hypertension. Clin Perinatol 2020; 47:593-615. [PMID: 32713453 DOI: 10.1016/j.clp.2020.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Neonatal pulmonary hypertension is a heterogeneous disease in term and preterm neonates. It is characterized by persistent increase of pulmonary artery pressures after birth (acute) or an increase in pulmonary artery pressures after approximately 4 weeks of age (chronic); both phenotypes result in exposure of the right ventricle to sustained high afterload. In-depth clinical assessment plus echocardiographic measures evaluating pulmonary blood flow, pulmonary vascular resistance, pulmonary capillary wedge pressure, and myocardial contractility are needed to determine the cause and provide individualized targeted therapies. This article summarizes the causes, risk factors, hemodynamic assessment, and management of neonatal pulmonary hypertension.
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Affiliation(s)
- Jessica Lauren Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Early postnatal cardiac follow-up of survivors of twin-twin transfusion syndrome treated with fetoscopic laser coagulation. J Perinatol 2020; 40:1375-1382. [PMID: 32152494 DOI: 10.1038/s41372-020-0645-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/25/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the cardiac function and prevalence of congenital heart defects (CHD) in twin-twin transfusion syndrome (TTTS) survivors. STUDY DESIGN Prospective follow-up of TTTS pregnancies treated with laser surgery (2015-2018). Echocardiography was performed 1 day and 1 month after birth (corrected for prematurity). Results were compared with a control group of age-matched uncomplicated monochorionic twin-pairs at 1 month. RESULT Eighty-nine TTTS (168 neonates) and nine control pregnancies (18 neonates) were enrolled. CHD birth prevalence was 9.2% (8/87) in recipients and 13.6% (11/81) in donors (p = 0.37). Four of 19 (21%) were detected prenatally, all pulmonary stenosis. Donors had lower aortic peak velocities compared with recipients at day 1 (0.66 ± 0.15 m/s vs 0.71 ± 0.19 m/s, p = 0.04) and 1 month (1.04 ± 0.21 m/s vs 1.11 ± 0.18 m/s, p = 0.02), but not compared with controls. CONCLUSION CHD prevalence in TTTS survivors is high, with a low prenatal detection of minor abnormalities. Follow-up fetal echocardiograms and a postnatal echocardiogram should be offered.
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Myocardial function in late preterm infants during the transitional period: comprehensive appraisal with deformation mechanics and non-invasive cardiac output monitoring. Cardiol Young 2020; 30:249-255. [PMID: 31845639 DOI: 10.1017/s1047951119003020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a paucity of functional data on mid-to-late preterm infants between 30+0 and 34+6 weeks gestation. We aimed to characterise transitional cardiopulmonary and haemodynamic changes during the first 48 hours in asymptomatic mid-to-late preterm infants. METHODS Forty-five healthy preterm newborns (mean ± standard deviation) gestation of 32.7 ± 1.2 weeks) underwent echocardiography on Days 1 and 2. Ventricular mechanics were assessed by speckle tracking-derived deformation, rotational mechanics, tissue Doppler imaging, and right ventricle-focused measures (tricuspid annular plane systolic excursion, fractional area change). Continuous haemodynamics were assessed using the NICOM™ system to obtain left ventricular output, stroke volume, heart rate, and total peripheral resistance by non-invasive cardiac output monitoring. RESULTS Right ventricular function increased (all measures p < 0.005) with mostly stable left ventricular performance between Day 1 and Day 2. NICOM-derived left ventricular output [mean 34%, 95% confidence interval 21-47%] and stroke volume [29%, 16-42%] increased with no change in heart rate [5%, -2 to 12%]. There was a rise in mean blood pressure [11%, 1-21%], but a decline in total peripheral resistance [-14%, -25 to -3%]. CONCLUSION Left ventricular mechanics remained persevered in mid-to-late premature infants, but right ventricular function increased. Non-invasive cardiac output monitoring is feasible in preterm infants with an increase in left ventricular output driven by an improvement in stroke volume during the transitional period.
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Bussmann N, Smith A, Cappelleri A, Levy PT, McCallion N, Franklin O, EL‐Khuffash A. Circumferential and radial deformation assessment in premature infants: Ready for primetime? Echocardiography 2019; 36:1532-1539. [DOI: 10.1111/echo.14442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Neidin Bussmann
- Department of Neonatology The Rotunda Hospital Dublin Ireland
| | - Aisling Smith
- Department of Neonatology The Rotunda Hospital Dublin Ireland
| | | | - Phillip T. Levy
- Division of Newborn Medicine Boston Children's Hospital Boston MA USA
| | - Naomi McCallion
- Department of Neonatology The Rotunda Hospital Dublin Ireland
- Department of Paediatrics School of Medicine Royal College of Surgeons in Ireland Dublin Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology Our Lady's Children's Hospital Crumlin Dublin Ireland
| | - Afif EL‐Khuffash
- Department of Neonatology The Rotunda Hospital Dublin Ireland
- Department of Paediatrics School of Medicine Royal College of Surgeons in Ireland Dublin Ireland
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